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Evolving Treatment Landscape of Relapsed/Refractory Follicular Lymphoma
Author(s):
A broad view of the current treatment paradigm for relapsed/refractory follicular lymphoma and how the field has been evolving.
Transcript:
Sameh R. Gaballa, MD: Dr Lunning, this is a good segue into my next question here, which is, how do you see the management of relapsed follicular lymphoma evolving? Now we’ve been getting more and more approvals. There are more options now, including approvals for bispecific antibodies, we have CAR [chimeric antigen receptor] T-cell therapy, we have chemoimmunotherapy. When you get a patient with relapsed/refractory follicular lymphoma, what’s typically your approach?
Matthew A. Lunning, DO, FACP: It depends upon how they’re relapsing and what they received in the first-line setting. I’ve characteristically used chemoimmunotherapy, typically bendamustine and rituximab, in the front line. I haven’t used a lot of obinutuzumab backbone in the first line, despite the GALLIUM study data. I haven’t been as big of a fan, going through and coming out of COVID-19, of maintenance rituximab, even in a metabolic CR [complete response] coming out of induction chemotherapy. Coming back to the to the relapsed/refractory setting, I am a believer in POD24 [progression of disease within 24 months from diagnosis], if you follow the POD24 characteristics. Over time, the POD24 designation has been watered down in the relapsed/refractory setting, where it wasn’t quite following the original paper by [Carla] Casulo, [MD]. It was very hard to tease out that population of patients who truly fit that higher risk relapsing disease. But if you do have a patient who received chemoimmunotherapy and their disease is telling you it’s coming back within a year or two, or they’re relapsing on maintenance rituximab, if you so choose to give it within 2 years from the start of therapy, I think that may color my discussion with the patient. But if they’re having asymptomatic relapses at 3 years, I’m not too keen on moving them into therapy, until they prove that they need therapy again.
I’m very conservative in the relapsed/refractory setting. I have characteristically used lenalidomide and rituximab, especially if I’ve used chemoimmunotherapy in the front line, as my second-line therapy, especially off of an AUGMENT [study]-like approach if they are rituximab sensitive. I do think that lenalidomide has a nice fit there. Obviously, clinical trials are quite appealing right now in the second-line setting, in regard to tazemetostat combining with lenalidomide in a randomized trial. I know there are bispecific trials moving into the second line. Also, I think that bispecifics will eventually challenge in the frontline setting. Are we seeing the evolution like we did in CLL [chronic lymphocytic leukemia] with putting novel therapies before chemoimmunotherapy? Are we just going to be slightly delayed in follicular lymphoma by 5 to 10 years before we are looking at getting to these chemotherapy-free regimens? When you talk about chemotherapy-free, you’re talking about your classical chemotherapies, like your CHOP [cyclophosphamide, doxorubicin, vincristine, prednisone], your bendamustine, and whether those are getting pushed further and further aside. I really like the movement that’s happening in follicular lymphoma. I think we’re approaching this in a very unique way.
Transcript edited for clarity.
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